Submitting claims

Provider and location details

Provider and practice location details can be set with a single providerNumber attribute. Importantly, this provider number must be defined and active in Tyro Health and for the given business API Key. Provider numbers which are not registered in Tyro Health or for the given business API key will error. Only one provider can claim per invoice.

Provider number formats can vary by type of professional category and issuing organisation. In general, the provider number will be defined as follows:

For the SDK, if a provider number is not sent in the claim payload, the the user will be prompted to manually select:

• The practice location
• Individual provider
• Provider profession type and/or specialist category
  

If only one of each category has been defined, that will be automatically selected.

Registration of provider numbers

Providers must first register with Tyro Health prior to submitting a icare claim. We do not currently offer an API for partners to self-register providers.

This registration process is self-service and can be completed within a few minutes. If providers deliver services from multiple locations or businesses, each unique provider number must be registered. Details on provider registration and icare activation is provided at: (https://help.medipass.com.au/en/articles/3800285-how-to-activate-icare-invoicing-in-medipass)

Patients

Patients For icare, a claim requires one valid patient/injured worker. Multiple patients are not supported - each must be submitted as a separate claim. A claim requires:

• firstName : which can be up to 40 characters, and only contain alpha (A-Z and a-z), numeric (0- 9), space ( ), apostrophe (') and hyphen (- ) characters. Spaces must not appear before or after apostrophes, hyphens, other spaces or the supplied value. At least one alpha or numeric character required. If the patient has only one name, set that in the lastName field and set firstName to “onlyname”.
  
• lastName : which can be up to 40 characters, and only contain alpha (A-Z and a-z), numeric (0- 9), space ( ), apostrophe (') and hyphen (- ) characters. Spaces must not appear before or after apostrophes, hyphens, other spaces or the supplied value. At least one alpha or numeric character required.
  
• accountNumber : icare claim number.
  
• refId (optional): An optional but highly recommended patient unique reference as set by you, such as a UUID/GUID. This value is used to uniquely identify a patient in the Tyro Health platform. Omitting refId will cause duplicate patient records to be created in Tyro Health and could make patient searches more difficult for providers who also use the Tyro Health portal to check on status of a claim and remittance. If supplied and valid, this value will pre-populate patient details from the patient record in the business as set in any prior claim. Any patient details set for an existing patient record will update those values and override what was previously stored.
  
• invoiceReference : which can be up to 16 characters,Should be globally unique across the business for search and reporting purposes.

Claim number is validated at claim submission and invalid details will be flagged with corresponding error details.

Items

Over 10,000 unique item codes - also referred to as service items, item numbers, material numbers or pay codes - are supported by Tyro Health for icare claims. This includes most medical provider items defined in the Medicare Benefits Schedule (MBS), Pharmaceuticals as defined in the PBS and others as defined by icare. Multiple service items with different dates of service can be included in a single claim.

Multiple item code sources are supported by the icare integration. In general item types and item codes can be defined as follows:

icare item codes are unique to the professional category, for example only acupuncture codes can be seen by Acupuncturists.

Item codes are updated dynamically by icare and new codes will be automatically integrated into the Tyro Health platform. Current icare item codes can be obtained via :(https://www.sira.nsw.gov.au/)

icare allows providers to determine their own fees for services. However, payment will only be made up to a maximum benefit amount for each service. If the amount charged by a provider exceeds icare Victoria's maximum price for an item, a warning will be displayed, but the item can be submitted and adjudicated as-is.

Approved claims will return a “benefit paid”, and the remaining amount will appear as a “gap” on the invoice. The service provider is permitted to charge the injured worker additional gap fees for amounts not covered by icare.

A valid claim will contain the following item attributes:

• serviceDateString : date of service in YYYY-MM-DD format. Past service dates are supported.
  
• itemCode : up to 12 characters. The item code must be applicable for a given service date and provider registered professional category. For MBS items, leading zeros are permitted or may be omitted. Items which are not known or invalid for a given service date or profession will be flagged with an error at the item level.
  
• price : net (excluding GST) price each unit in $XX.XX format.
  

Units of measure vary depending on item code. The current supported icare units of measure include:

• customDescription (optional): a description of the item up to 128 characters. Only used and required for special catch-all items, such as AIDNR - Aids & appliances - Non Rehab. If a description is required for the item and not provided, an error response will be returned at the item level.
  
• gstInclusiveFlag (optional): indicates if GST should be applied for the item. Note that services delivered to a patient are typically GST free. Services delivered for the insurer/agent may attract GST. Default is false. If set to true, GST of 10% will be added to the price amount.